[104-10222-10042.pdf — page 184]
# HEALTH QUALIFICATION PLACEMENT RECORD(This section is comparable to Standard Form 90 promulgated March 1945 by Bureau of the Budget Circular A-24)1. L MR   MRS   MISS   Charlotte Bearing2. DATE OF BIRTH   January 18, 19393. MALE   FEMALE4. ADDRESS5. TITLE OF POSITION   San m.e Garden, Ayton 9, Ohio   Statistical Draftsman6. DEPARTMENT OR BUREAU IN WHICH YOU ARE TO BE EMPLOYED7. LOCATION   Interior - Division of Geography   Washington, D. C.8. ARE YOU NOW EMPLOYED IN THE POSITION SHOWN IN ITEM 5? YES NO IF YOUR ANSWER IS YES, GIVE THE DATE OF YOUR ORIGINAL APPOINTMENT TO THIS POSITION:TO BE COMPLETED BY APPOINTING OFFICER: Sections 9 and 10(A) BRIEF OUTLINE OF WHAT WORKER DOES(B) PHYSICAL DEMANDS OF THE POSITIONFor the physician's use, set down in brief and simple terms what the employee does on this job, including environmental details such as stairs to climb, distance to rest-room facilities, cafeteria, work-shift, etc. (Use Section 9 below.)In Section 10 below encircle the number of those factors which are essential to the duties of the position for which this applicant is being considered. The blank spaces may be used for special factors not listed.9. TITLE OF POSITION AND OUTLINE OF WHAT WORKER DOES IN THIS POSITION (Aditors of dictionary of occupational titles as guide, see applicable)Statistical Draftsman - To assist in the performance of drafting, lettering and incidental statistical clerical work in the preparation and revision of index maps, showing the location of approved and disapproved names and the extent of features to which names apply; charts, graphs and other illustrative materials in connection with the functions of the Research Branch and for administrativo purposes.TO BE COMPLETED BY EXAMINING PHYSICIAN: Sections 10, 11, 12, 13, 14, and 15INSTRUCTIONS: The iterus lited below indicate the physical requirements of the position for which this individual is being considered. Indicate the individual's physical capacities for this position by placing an X in the appropriate column opposite the numbers encircled. If the individual has any other physical limitations relating to physical requirements not encircled or not covered by this form, indicate these under "Remarks" on the reverse side. Whenever PARTIAL capacity has been indicated, explain under "Remarks," giving specific quantities.PHYSICAL REQUIREMENTSENVIRONMENTAL FACTORS|                                         | CAPACITY |         |      || --------------------------------------- | -------- | ------- | ---- ||                                         | FULL     | PARTIAL | NONE || 1. OUTSIDE                              |          |         |      || 2. OUTSIDE AND INSIDE                   |          |         |      || 3. EXCESSIVE HEAT                       |          |         |      || 4. EXCESSIVE COLD                       |          |         |      || 5. EXCESSIVE HUMIDITY                   |          |         |      || 6. EXCESSIVE DAMPNESS OF CHILLING       |          |         |      || 7. DRY ATMOSPHERIC CONDITIONS           |          |         |      || 8. EXCESSIVE NOISE INTERMITTENT         |          |         |      || 9. CONSTANT NOISE                       |          |         |      || 10. DUST                                |          |         |      || 11. SILICA, ASBESTOS, ETC.              |          |         |      || 12. FUMES, SMOKE, OR GASES              |          |         |      || 13. SOLVENTS (Specify)                  |          |         |      || 14. GREASES AND OILS                    |          |         |      || 15. RADIANT ENERGY                      |          |         |      || 16. ELECTRICAL ENERGY                   |          |         |      || 17. SLIPPERY OR UNEVEN WALKING SURFACES |          |         |      ||                                                | CAPACITY |         |      || ---------------------------------------------- | -------- | ------- | ---- ||                                                | FULL     | PARTIAL | NONE || 18. WORKING AROUND MACHINERY WITH MOVING PARTS |          |         |      || 19. WORKING ON LADDERS OR SCAFFOLDING          |          |         |      || 20. WORKING BELOW GROUND                       |          |         |      || 21. LOCAL FATIGUE FACTORS (Specify)            |          |         |      || 22. WORKING WITH HANDS IN WATER                |          |         |      || 23. EXPLOSIVES                                 |          |         |      || 24. VIBRATION                                  |          |         |      || 25. WORKING CLOSELY WITH OTHERS                |          |         |      || 26. WORKING ALONE                              |          |         |      || 27. PROTRACTED OR IRREGULAR HOURS OF WORK      |          |         |      || 28. SOCIAL FACTORS (Specify)                   |          |         |      || 29.                                            |          |         |      || 30.                                            |          |         |      |16-44611-1